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The efficacy and safety of cinacalcet in primary hyperparathyroidism: a systematic review and meta-analysis of randomized controlled trials and cohort studies

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Abstract

Cinacalcet, a positive allosteric modulator of the calcium sensing receptor (CaSR) reduces parathyroid hormone (PTH) secretion by increasing the sensitivity of the CaSR on parathyroid cells. We conducted a systematic review and meta-analysis on the safety and efficacy of cinacalcet in Primary Hyperparathyroidism (PHPT). MEDLINE, Embase, BIOSIS, and the Cochrane Library were searched for published articles (from database inception to Sept 2020). All double-blind RCTs and cohort studies that reported data on the efficacy and safety of cinacalcet therapy in individuals ≥ 18 with PHPT were included. Random effect meta-analysis was performed to estimate the efficacy of cinacalcet in lowering serum calcium and PTH levels compared with placebo. 4 RCTs (177 participants) and 17 cohort studies (763 participants) were eligible for final analysis. Pooled results from the RCTs suggest that, when compared to placebo and administered for up to 28 weeks, cinacalcet normalizes serum calcium (≤ 10.3 mg/dl) in patients with PHPT [RR 20 (95% CI 6.04 – 68.52, I2 = 0%, pheterogeneity < 0·00001)]. Serum PTH levels decreased significantly after 2 weeks and up to 28 weeks after treatment with cinacalcet. In the pooled analysis of the 17 cohort studies, serum calcium levels normalized in 76% (95% CI 66% to 86%; I2 = 92%, pheterogeneity < 0·00001) of patients regardless of the duration of treatment. In most studies, PTH levels decreased by 13% to 55%. No RCT reported on BMD as a primary or secondary outcome, and no improvement in BMD was noted in the 2 non-randomized studies that reported densitometric findings. No significant difference in urinary calcium was noted with cinacalcet therapy in either the RCTs or non-randomized studies. There was no significant difference in overall adverse events (AE) (RD 0.01, 95% CI –0.07 to 0.26) compared to placebo noted in the RCTs. In the non-randomized studies, pooled weighted AE rate was 45% (95% CI 32 to 59%). Risk of bias was low in 2/4 RCTs and 6/17cohort studies; risk was intermediate in 2/4 RCTs and 8/17 cohort studies, and risk was high in 3/17 cohort studies. In PHPT, cinacalcet lowers serum calcium and PTH with greater effects on calcium than on PTH in the short term. In the doses reported, the drug is safe with tolerable side effects. These findings can help inform targeted medical therapy of PHPT in those for whom lowering the serum calcium is indicated and for whom parathyroidectomy is not an option.

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Author notes

  1. Manju Chandran and John P. Bilezikian have joint first authorship.

Authors and Affiliations

  1. Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, DUKE-NUS Graduate Medical School, Singapore, Singapore

    Manju Chandran

  2. Department of Medicine, Division of Endocrinology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA

    John P. Bilezikian

  3. Division of Endocrine Surgery, National University Hospital, Singapore, Singapore

    Joel Lau & Rajeev Parameswaran

  4. Buckingham Medical School, University of Buckingham, Buckingham, UK

    Reshma Rajeev

  5. Division of Endocrinology, Department of Medicine, National University Hospital Singapore, Singapore, Singapore

    Samantha Peiling Yang

  6. Research Support Unit, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore

    Miny Samuel

  7. Department of Surgery, National University of Singapore, Singapore, 117597, Singapore

    Rajeev Parameswaran

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Contributions

MC, MS, and RP approved of final studies included into the Systematic Review and drafted the initial manuscript. RR and JL screened the literature identified using the search protocol, and abstracted data from selected studies. MC and JPB provided content expertise and reviewed and edited the manuscript. SPY helped review the manuscript. MC, JPB, JL, SPY, RR, MS and RP approved the final manuscript as submitted.

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Correspondence to Manju Chandran.

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Chandran, M., Bilezikian, J.P., Lau, J. et al. The efficacy and safety of cinacalcet in primary hyperparathyroidism: a systematic review and meta-analysis of randomized controlled trials and cohort studies. Rev Endocr Metab Disord 23, 485–501 (2022). https://doi.org/10.1007/s11154-021-09694-6

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